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Quadri SS, Culver SA, Li C, Siragy HM. Interaction of the renin angiotensin and cox systems in the kidney. Front Biosci (Schol Ed) 2016; 8:215-26. [PMID: 27100703 DOI: 10.2741/s459] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cyclooxygenase-2 (COX-2) plays an important role in mediating actions of the renin-angiotensin system (RAS). This review sheds light on the recent developments regarding the complex interactions between components of RAS and COX-2; and their implications on renal function and disease. COX-2 is believed to counter regulate the effects of RAS activation and therefore counter balance the vasoconstriction effect of Ang II. In kidney, under normal conditions, these systems are essential for maintaining a balance between vasodilation and vasoconstriction. However, recent studies suggested a pivotal role for this interplay in pathology. COX-2 increases the renin release and Ang II formation leading to increase in blood pressure. COX-2 is also associated with diabetic nephropathy, where its upregulation in the kidney contributes to glomerular injury and albuminuria. Selective inhibition of COX-2 retards the progression of renal injury. COX-2 also mediates the pathologic effects of the (Pro)renin receptor (PRR) in the kidney. In summary, this review discusses the interaction between the RAS and COX-2 in health and disease.
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Affiliation(s)
- Syed S Quadri
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, VA
| | - Silas A Culver
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, VA
| | - Caixia Li
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, VA,
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Abadir PM, Siragy HM. Angiotensin type 1 receptor mediates renal production and conversion of prostaglandins E2 to F2α in conscious diabetic rats. J Renin Angiotensin Aldosterone Syst 2015. [PMID: 26195268 DOI: 10.1177/1470320315592566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Previous studies demonstrated that stimulation of angiotensin subtype 1 receptor (AT1R) led to increased renal generation of prostaglandins E2 (PGE2) and renal inflammation. In turn, PGE2 increases AT1R activity. The conversion of PGE2 to the less active metabolite prostaglandin F2α (PGF2α) via 9-ketoreductase interrupts this feedback loop. The effects of diabetes on the interface between AT1R, PGE2 and PGF2α are not well established. We hypothesized that in diabetes, an aberrant AT1R activity enhances the biosynthesis of PGE2 and impairs the activity of PGE 9-ketoreductase, leading to accumulation of PGE2. MATERIALS AND METHODS Using microdialysis technique, we monitored renal interstitial fluid levels of angiotensin II (Ang II), PGE2 and PGF2α in control and AT1R blocker, valsartan, treated diabetic rats (N=8 each). We utilized the PGF2α to PGE2 ratio as indirect measure of PGE 9-ketoreductase activity. RESULTS Diabetes increased renal interstitial fluid levels of Ang II, PGE2 and PGF2α. PGF2α/PGE2 ratio increased by the third week, but declined by the sixth week of diabetes. Valsartan reduced PGE2 and PGF2α levels and increased Ang II and the conversion of PGE2 to PGF2α. CONCLUSION Our results suggest that in diabetes, AT1R increases PGE2 generation and reduces conversion of PGE2 to PGF2α with the progression of diabetes.
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Affiliation(s)
- Peter M Abadir
- Johns Hopkins University, Division of Geriatrics Medicine and Gerontology, Baltimore, USA
| | - Helmy M Siragy
- University of Virginia School of Medicine, Department of Medicine, Charlottesville, USA
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Sourris KC, Morley AL, Koitka A, Samuel P, Coughlan MT, Penfold SA, Thomas MC, Bierhaus A, Nawroth PP, Yamamoto H, Allen TJ, Walther T, Hussain T, Cooper ME, Forbes JM. Receptor for AGEs (RAGE) blockade may exert its renoprotective effects in patients with diabetic nephropathy via induction of the angiotensin II type 2 (AT2) receptor. Diabetologia 2010; 53:2442-51. [PMID: 20631980 PMCID: PMC4926314 DOI: 10.1007/s00125-010-1837-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 05/20/2010] [Indexed: 12/13/2022]
Abstract
AIMS/HYPOTHESIS The receptor for AGEs (RAGE) contributes to the development and progression of diabetic nephropathy. In this study, we examined whether the protective effects of RAGE blockade are exerted via modulation of the renal angiotensin II type 2 (AT2) receptor. METHODS Control and streptozotocin diabetic mice, wild-type or deficient in the AT2 receptor (At2 knockout [KO]) or RAGE (Rage KO), were studied for 24 weeks. Adenoviral overexpression of full-length Rage in primary rat mesangial cells was also used to determine the effects on AT2 production. RESULTS With diabetes, Rage-deficient mice had less albuminuria, and an attenuation of hyperfiltration and glomerulosclerosis as compared with diabetic wild-type and At2 KO mice. Renal gene and protein expression of RAGE was elevated with diabetes. Diabetic Rage KO mice had a greater increase in renal AT2 receptor protein than was seen in diabetic wild-type mice. Diabetes-induced increases in renal cytosolic and mitochondrial superoxide generation were prevented in diabetic Rage KO mice, but enhanced in all At2 KO mice. Adenoviral overexpression of RAGE or AGE treatment decreased cell surface AT2 expression, in association with increasing superoxide generation; both were reversed using antioxidants N-acetylcysteine and apocynin, and soluble RAGE in primary mesangial cells. CONCLUSIONS/INTERPRETATION RAGE appears to be a common and key modulator of AT2 receptor expression, a finding that would implicate a newly defined RAGE-AT2 axis in the development and progression of diabetic nephropathy.
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Affiliation(s)
- K C Sourris
- JDRF Einstein Centre for Diabetes Complications, Baker Heart Research Institute, PO Box 6492, St Kilda Rd Central, Melbourne, Victoria, 8008, Australia.
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Saito O, Guan Y, Qi Z, Davis LS, Kömhoff M, Sugimoto Y, Narumiya S, Breyer RM, Breyer MD. Expression of the prostaglandin F receptor (FP) gene along the mouse genitourinary tract. Am J Physiol Renal Physiol 2003; 284:F1164-70. [PMID: 12631554 DOI: 10.1152/ajprenal.00441.2002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PGF(2alpha) is one of the major prostanoids produced by the kidney. The cellular effects of PGF(2alpha) are mediated by a G protein-coupled transmembrane receptor designated the FP receptor. Both in situ hybridization and beta-galactosidase knocked into the endogenous FP locus were used to determine the cellular distribution of the mouse FP receptor. Specific labeling was detected in the kidney, ovary, and uterus. Abundant FP expression in ovarian follicles and uterus is consistent with previous reports of failed parturition in FP-/- mice. In the kidney, coexpression of the mFP mRNA with the thiazide-sensitive cotransporter defined its expression in the distal convoluted tubule (DCT). FP receptor was also present in aquaporin-2-positive cortical collecting ducts (CCD). No FP mRNA was detected in glomeruli, proximal tubules, or thick ascending limbs. Intrarenal expression of the FP receptor in the DCT and CCD suggests an important role for the FP receptor regulating water and solute transport in these segments of the nephron.
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Affiliation(s)
- Osamu Saito
- Division of Nephrology, Department of Medicine, Vanderbilt University Veterans Affairs Medical Center, Nashville, Tennessee 37212, USA
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Nakamura S, Averill DB, Chappell MC, Diz DI, Brosnihan KB, Ferrario CM. Angiotensin receptors contribute to blood pressure homeostasis in salt-depleted SHR. Am J Physiol Regul Integr Comp Physiol 2003; 284:R164-73. [PMID: 12482748 DOI: 10.1152/ajpregu.00210.2002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study evaluated the contribution of angiotensin peptides acting at various receptor subtypes to the arterial pressure and heart rate of adult 9-wk-old male conscious salt-depleted spontaneously hypertensive rats (SHR). Plasma ANG II and ANG I in salt-depleted SHR were elevated sevenfold compared with peptide levels measured in sodium-replete SHR, whereas plasma ANG-(1-7) was twofold greater in salt-depleted SHR compared with salt-replete SHR. Losartan (32.5 micromol/kg), PD-123319 (0.12 micromol. kg(-1). min(-1)), [d-Ala(7)]ANG-(1-7) (10 and 100 pmol/min), and a polyclonal ANG II antibody (0.08 mg/min) were infused intravenously alone or in combination. Combined blockade of AT(2) and AT((1-7)) receptors significantly increased the blood pressure of losartan-treated SHR (+15 +/- 1 mmHg; P < 0.01); this change did not differ from the blood pressure elevation produced by the sole blockade of AT((1-7)) receptors (15 +/- 4 mmHg). On the other hand, sole blockade of AT(2) receptors in losartan-treated SHR increased mean arterial pressure by 8 +/- 1 mmHg (P < 0.05 vs. 5% dextrose in water as vehicle), and this increase was less than the pressor response produced by blockade of AT((1-7)) receptors alone or combined blockade of AT((1-7)) and AT(2) receptors. The ANG II antibody increased blood pressure to the greatest extent in salt-depleted SHR pretreated with only losartan (+11 +/- 2 mmHg) and to the least extent in salt-depleted SHR previously treated with the combination of losartan, PD-123319, and [d-Ala(7)]ANG-(1-7) (+7 +/- 1 mmHg; P < 0.01). Losartan significantly increased heart rate, whereas other combinations of receptor antagonists or the ANG II antibody did not alter heart rate. Our results demonstrate that ANG II and ANG-(1-7) act through non-AT(1) receptors to oppose the vasoconstrictor actions of ANG II in salt-depleted SHR. Combined blockade of AT(2) and AT((1-7)) receptors and ANG II neutralization by the ANG II antibody reversed as much as 67% of the blood pressure-lowering effect of losartan.
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Affiliation(s)
- Shigefumi Nakamura
- Hypertension and Vascular Disease Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Zimpelmann J, Burns KD. Angiotensin II AT(2) receptors inhibit growth responses in proximal tubule cells. Am J Physiol Renal Physiol 2001; 281:F300-8. [PMID: 11457722 DOI: 10.1152/ajprenal.2001.281.2.f300] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Angiotensin II (ANG II) subtype 2 (AT(2)) receptors are expressed in the adult kidney, but the effects of AT(2) receptor activation are unclear. The proximal tubule cell line LLC-PK(1) was transfected with a plasmid containing cDNA for the rat AT(2) receptor. In transfected cells, specific binding of (125)I-labeled ANG II was detected (dissociation constant = 0.81 nM), with inhibition by the AT(2) antagonist PD-123319, and no effect of the AT(1) antagonist losartan. ANG II (10(-7) M) significantly inhibited mitogen-activated protein kinase (MAPK) activity in transfected cells, associated with decreased phosphorylation of the extracellular signal-related kinases ERK1 and ERK2. ANG II stimulated phosphotyrosine phosphatase activity within 5 min, an effect blocked by PD-123319 and the phosphatase inhibitor vanadate. In transfected cells, ANG II inhibited epidermal growth factor-stimulated [(3)H]thymidine incorporation, an effect reversed by vanadate. In contrast, vanadate did not block ANG II-stimulated apoptosis of transfected cells. In summary, AT(2) receptors in proximal tubule cells inhibit MAPK activity and stimulate phosphotyrosine phosphatase. AT(2) receptor-induced inhibition of mitogenesis is mediated by phosphatase activation, whereas effects on apoptosis are insensitive to phosphatase inhibition. The data suggest that AT(2) receptors inhibit cell growth via distinct signaling pathways in the proximal tubule.
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Affiliation(s)
- J Zimpelmann
- Department of Medicine, Ottawa Hospital, and the Kidney Research Centre, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada K1H 8L6
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Abstract
Renal cyclooxygenase 1 and 2 activity produces five primary prostanoids: prostaglandin E2, prostaglandin F2alpha, prostaglandin I2, thromboxane A2, and prostaglandin D2. These lipid mediators interact with a family of distinct G protein-coupled prostanoid receptors designated EP, FP, IP, TP, and DP, respectively, which exert important regulatory effects on renal function. The intrarenal distribution of these prostanoid receptors has been mapped, and the consequences of their activation have been partially characterized. FP, TP, and EP1 receptors preferentially couple to an increase in cell calcium. EP2, EP4, DP, and IP receptors stimulate cyclic AMP, whereas the EP3 receptor preferentially couples to Gi, inhibiting cyclic AMP generation. EP1 and EP3 mRNA expression predominates in the collecting duct and thick limb, respectively, where their stimulation reduces NaCl and water absorption, promoting natriuresis and diuresis. The FP receptor is highly expressed in the distal convoluted tubule, where it may have a distinct effect on renal salt transport. Although only low levels of EP2 receptor mRNA are detected in the kidney and its precise intrarenal localization is uncertain, mice with targeted disruption of the EP2 receptor exhibit salt-sensitive hypertension, suggesting that this receptor may also play an important role in salt excretion. In contrast, EP4 receptor mRNA is predominantly expressed in the glomerulus, where it may contribute to the regulation of glomerular hemodynamics and renin release. The IP receptor mRNA is highly expressed near the glomerulus, in the afferent arteriole, where it may also dilate renal arterioles and stimulate renin release. Conversely, TP receptors in the glomerulus may counteract the effects of these dilator prostanoids and increase glomerular resistance. At present there is little evidence for DP receptor expression in the kidney. These receptors act in a concerted fashion as physiological buffers, protecting the kidney from excessive functional changes during periods of physiological stress. Nonsteroidal anti-inflammatory drug (NSAID)-mediated cyclooxygenase inhibition results in the loss of these combined effects, which contributes to their renal effects. Selective prostanoid receptor antagonists may provide new therapeutic approaches for specific disease states.
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Affiliation(s)
- M D Breyer
- Division of Nephrology, Department of Medicine, Vanderbilt University, Nashville, Tennessee 37232, USA.
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Carey RM, Wang ZQ, Siragy HM. Update: role of the angiotensin type-2 (AT(2)) receptor in blood pressure regulation. Curr Hypertens Rep 2000; 2:198-201. [PMID: 10981149 DOI: 10.1007/s11906-000-0082-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the past, virtually all of the physiologic actions of angiotensin II (ANG II) were thought to be mediated by the type-1 ANG II receptor. However, there is now a compelling body of evidence suggesting that the type-2 (AT2) receptor is an important regulator of renal function and blood pressure (BP). The AT2 receptor stimulates a bradykinin (BK)-nitric oxide (NO)-cyclic GMP vasodilator cascade in blood vessels and in the kidney. Recent studies have shown that absence of the AT2 receptor lends to pressor and natriuretic hypersensitivity to ANG II. Furthermore, there is now excellent evidence that the AT2 receptor mediates pressure natriuresis. The AT2 receptor also stimulates the conversion of prostaglandin E2 (PGE2) to PGF2. In addition, it is now apparent that the therapeutic reduction in BP with AT1 receptor blockade (eg, losartan, valsartan, candesartan) is mediated by ANG II stimulation of the AT2 receptor, leading to increased levels of BK, NO, and cGMP. Current evidence predicts that AT2 receptor agonists would be beneficial in the treatment of hypertension.
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Affiliation(s)
- R M Carey
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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Arima S, Ito S. Angiotensin II type 2 receptors in the kidney: evidence for endothelial-cell-mediated renal vasodilatation. Nephrol Dial Transplant 2000; 15:448-51. [PMID: 10727534 DOI: 10.1093/ndt/15.4.448] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
MESH Headings
- Angiotensin II/antagonists & inhibitors
- Angiotensin II/metabolism
- Angiotensin Receptor Antagonists
- Animals
- Antihypertensive Agents/pharmacology
- Cell Division
- Endothelium, Vascular/cytology
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/metabolism
- Humans
- Hypertension, Renal/metabolism
- Hypertension, Renal/pathology
- Hypertension, Renal/prevention & control
- Kidney/blood supply
- Kidney/drug effects
- Kidney/metabolism
- Receptor, Angiotensin, Type 1
- Receptor, Angiotensin, Type 2
- Receptors, Angiotensin/metabolism
- Renal Circulation/drug effects
- Renal Circulation/physiology
- Signal Transduction
- Vasodilation/drug effects
- Vasodilation/physiology
- Vasodilator Agents/pharmacology
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Gallinat S, Busche S, Raizada MK, Sumners C. The angiotensin II type 2 receptor: an enigma with multiple variations. Am J Physiol Endocrinol Metab 2000; 278:E357-74. [PMID: 10710489 DOI: 10.1152/ajpendo.2000.278.3.e357] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Since it was discovered ten years ago, the angiotensin II (ANG II) type 2 (AT(2)) receptor has been an enigma. This receptor binds ANG II with a high affinity but is not responsible for mediating any of the classical physiological actions of this peptide, all of which involve the ANG II type 1 (AT(1)) receptor. Furthermore, the AT(2) receptor exhibits dramatic differences in biochemical and functional properties and in patterns of expression compared with the AT(1) receptor. During the past decade, much information has been gathered about the AT(2) receptor, and the steadily increasing number of publications indicates a growing interest in this new and independent area of research. A number of studies suggest a role of AT(2) receptors in brain, renal, and cardiovascular functions and in the processes of apoptosis and tissue regeneration. Despite these advances, nothing stands out as the major singular function of these receptors. The study of AT(2) receptors has reached a crossroads, and innovative approaches must be considered so that unifying mechanisms as to the function of these unique receptors can be put forward. In this review we will discuss the advances that have been made in understanding the biology of the AT(2) receptor. Furthermore, we will consider how these discoveries, along with newer experimental approaches, may eventually lead to the elusive physiological and pathophysiological functions of these receptors.
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Affiliation(s)
- S Gallinat
- Department of Physiology, College of Medicine, and University of Florida Brain Institute, University of Florida, Gainesville, Florida 32610, USA
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Siragy HM, Senbonmatsu T, Ichiki T, Inagami T, Carey RM. Increased renal vasodilator prostanoids prevent hypertension in mice lacking the angiotensin subtype-2 receptor. J Clin Invest 1999; 104:181-8. [PMID: 10411547 PMCID: PMC408474 DOI: 10.1172/jci6063] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The angiotensin subtype-1 (AT(1)) receptor mediates renal prostaglandin E(2) (PGE(2)) production, and pharmacological blockade of the angiotensin subtype-2 (AT(2)) receptor potentiates the action of angiotensin II (Ang II) to increase PGE(2) levels. We investigated the role of the AT(2) receptor in prostaglandin metabolism in mice with targeted deletion of the AT(2) receptor gene. Mice lacking the AT(2) receptor (AT(2)-null) had normal blood pressure that was slightly elevated compared with that of wild-type (WT) control mice. AT(2)-null mice had higher renal interstitial fluid (RIF) 6-keto-PGF(1alpha) (a stable hydrolysis product of prostacyclin [PGI(2)]) and PGE(2) levels than did WT mice, and had similar increases in PGE(2) and 6-keto-PGF(1alpha) in response to dietary sodium restriction and Ang II infusion. In contrast, AT(2)-null mice had lower PGF(2alpha) levels compared with WT mice during basal conditions and in response to dietary sodium restriction or infusion of Ang II. RIF cAMP was markedly higher in AT(2)-null mice than in WT mice, both during basal conditions and during sodium restriction or Ang II infusion. AT(1) receptor blockade with losartan decreased PGE(2), PGI(2), and cAMP to levels observed in WT mice. To determine whether increased vasodilator prostanoids prevented hypertension in AT(2)-null mice, we treated AT(2)-null and WT mice with indomethacin for 14 days. PGI(2), PGE(2), and cAMP were markedly decreased in both WT and AT(2)-null mice. Blood pressure increased to hypertensive levels in AT(2)-null mice but was unchanged in WT. These results demonstrate that in the absence of the AT(2) receptor, increased vasodilator prostanoids protect against the development of hypertension.
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Affiliation(s)
- H M Siragy
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
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Carey RM, Wang ZQ, Siragy HM. Novel actions of angiotensin II via its renal type-2 (AT(2)) receptor. Curr Hypertens Rep 1999; 1:151-7. [PMID: 10981059 DOI: 10.1007/s11906-999-0012-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The vast majority of the biologic effects of angiotensin II have been considered to be mediated by the subtype-1 (AT(1)) receptor. The AT(2) receptor is expressed to a low degree in most adult cells and tissues, and its function has not been understood. Recent studies, however, have identified novel actions of angiotensin II mediated by the AT(2) receptor in the kidney. These AT(2) receptor actions have importance in the control of blood pressure and hypertension. The AT(2) receptor mediates a renal vasodilator cascade, including generation of bradykinin, nitric oxide, and cyclic GMP. This action of angiotensin II occurs when the renin-angiotensin system is activated, as in sodium depletion. The AT(2) receptor also appears to mediate prostaglandin (PG) F(2)(a) formation, probably by stimulating conversion of PGE2 to PGF(2)(a). The AT(2) receptor plays a counter-regulatory vasodilator role opposing the vasoconstrictor actions of angiotensin II. The AT(1) and AT(2) receptors engage in inter-receptor "cross-talk." In the absence of the AT(2) receptor, sustained angiotensin II pressor and antinatriuretic hypersensitivity occurs, mediated by a deficiency of bradykinin, nitric oxide, and cyclic GMP. The AT(2) receptor may play an important role in stimulating pressure natriuresis, but definitive studies are required to resolve this issue. The AT(2) receptor mediates several renal actions of angiotensin II, appears to be important in the physiologic regulation of blood pressure, and may be involved in the pathophysiology of hypertension.
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Affiliation(s)
- R M Carey
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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